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of � UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 4.AMENDED PERMIT5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8 TANK REMOVED B SINESS NAME(Same asFACILITY NAME DBA- Ding Business As) 3. 1 FACILITY ID: 1 �F S deft <SDh-3t6 LOCATION WITHIN SITE(Optional) 431. 1.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shalt be submitted to the local agency.) TANK/ISD# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑ 434. Yes No rTw If"Yes,"complete one page for each compartment DATE INSTALLED 435• TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS (YEAWMO an ADDITIONAL DESCRIPTION(For local use only) 438. II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 1. MOTOR VEHICLE F440 z FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If checked,complete Petroleum Type) 19'lb. PREMIUM UNLEADED ❑3. DIESEL C12. NON-FUEL PETROLEUM !❑'lc. MIDGRADE UNLEADED ❑6. AVIATION GAS ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441• CAS#(from Hazardous Materials Invento 442. ❑ 4. HAZARDOUS WASTE ry Page) (Includes Used Oil) ❑ 95.UNKNOWN 111.TANK CONSTRUCTION TYPE OF TANK ❑L SINGLE WALL ❑3. SINGLE WALL WI"fH EXTERIGR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) MEMBRANE LINER ❑95. UNKNOWN . DOUBLE WALL 4. SINGLE WALL[N A VAULT ❑99. OTHER TANK MATERIAL-primary tank 1. BARE STEEL �+3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100°/METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL 3. FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL 95.UNKNOWN 445, (Check one item only) ❑2. STAINLESS STEEL 4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL [15. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINING 5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ❑6.UNLINED 1199.OTHER Check one item only) OTHER CORROSION 1.MANUFACTURED CATHODIC 3.FIBERGLASS REINFORCED PLASTIC 95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER [fA Gcable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450, TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) 1.SPILL CONTAINMENT 1 (Q C/� ❑1.ALARM ❑2.DROP TUBE 3.FILL TUBE SHUT OFF VALVE ❑3.STRIKER PLATF. ❑2.BALL FLOAT U 4.EXEMPT IV.TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK (Check all that apply) 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 45a. ElMTG 1.VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING (Check one item only) ( ) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE �'L.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER a❑3.MANUAL MONITORING ❑4.STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99.OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE RENIAINING 456. TANK FILLED WITH INERT MATERIAL? 452 gallons [I Yes El No UPCF hwfwrc-b(1/99)-1/4 http://Www.unidocs.otg Rev.02/16/00